Stiff Shoulder & Cuff Tear. Cause & Management for Shoulder Stiffness after AS Rotator Cuff Repair. Idiopathic Frozen Shoulders. Hiroyuki Sugaya, MD

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Sports Medicine & Joint Center Funabashi Orthopaedic Hospital Cause & Management for Shoulder Stiffness after AS Rotator Cuff Repair Hiroyuki Sugaya, MD Stiff Shoulder & Cuff Tear Stiff shoulder

Associated w/ full-thickness RCT Frequently associated with rotator cuff lesions Cuff lesion can be a cause?

1 Sports Medicine & Joint Center Funabashi Orthopaedic Hospital Cause & Management for Shoulder Stiffness after AS Rotator Cuff Repair Hiroyuki Sugaya, MD Stiff Shoulder & Cuff Tear Stiff shoulder associated with rotator cuff tears Shoulder Stiffness after rotator cuff repair Cause Idiopathic Frozen Shoulders Stiff shoulders Associated w/ intact cuff Associated w/ partial-thickness RCT Associated w/ full-thickness RCT Frequently associated with rotator cuff lesions Cuff lesion can be a cause?? Watson L, JSES, 2000 Rundquist PJ, Clin Biomech 2004 Yoo JC, Orthopedics 2009 Idiopathic Frozen Shoulders Criteria of ROM loss No standardized criteria!! Variable according to authors Robinson CM, 2012 Abd<90 some limits in IR & ER Yoo JC, 2009 FF<100 ER<10 IR<Th12 Watson L, 2000 Abduction<120 ER<50% Pain can affect ROM!! ROM Measurement Measurement in standing or sitting position unreliable! Pain often restricts the motion! 1

Our Criteria FF 100 ER @ side 10 IR L5 Severe & Global Loss!

associated with ROM deficit Subjects Prospective Level IIa study July, 2012 - July, 2013 Exclusion criteria Diabetes mellitus Evident

2052 patients 379 shoulders in 367 patients 162 males & 205 females Mean age: 61 years (range, 35-83) Grouping by Severity & Pattern

2 Our Criteria FF 100 side 10 IR L5 Severe & Global Loss! Subjects Prospective Level IIa study July, July, shoulders in 2052 patients Age: 35 years and older Shoulder pain associated with ROM deficit Subjects Prospective Level IIa study July, July, 2013 Exclusion criteria Diabetes mellitus Evident traumatic event Calcific deposit Osteoarthritic change Subjects Prospective Level IIa study June, July, shoulders in 2052 patients 379 shoulders in 367 patients 162 males & 205 females Mean age: 61 years (range, 35-83) Grouping by Severity & Pattern FF, side, IR Grouping Severe & global loss group Severe, but not global group Mild & moderate group Grouping by Severity & Pattern FF 100 side 10 IR L5 Severe & global loss! Frozen shoulder Adhesive capsulitis 2

3 Grouping by Severity & Pattern FF 100 side = 30 IR L5 Severe, but not global! Grouping by Severity & Pattern FF =110 side = 20 IR = L4 Mild & moderate loss! 379 Stiff Shoulders 89 Severe & global loss 26 males, 63 females Average age: 57 (35-80) years 111 Severe, but not global loss 56 males, 55 females Average age: 60 (38-83) years 179 Mild & moderate loss 82 males, 97 females Average age: 63 (35-83) years Results: Rotator Cuff Lesions Severe & global (n=89) Severe, but not global (n=111) Mild & Moderate (n=179) Intact PTT FTT 91% (81) 44% (49) 35% (62) 9% (8) 17% (19) 16% (35) 0% (0) 39% (43) 50% (89) PTT: Partial-thickness tears, FTT: Full-thickness tears Shoulder stiffness associated with rotator cuff tears Severe and global loss Intact Summary Partial-thickness tears Full-thickness tears Mild and moderate loss Management Severe and global loss Intact or partial-thickness RCT Conservative Tx AS pan-capsular release only No need to repair P-T RCT!! Cuff repair may cause further stiffness 3

4 Management Full-thickness tears Mild and moderate loss Manipulation & Repair! Comparative outcome can be expected with no stiffness & repair Preop physio may be unnecessary Sabzevari, et al, JSES, 2017 Stiff Shoulder & Cuff Tear Stiff shoulder associated with rotator cuff tears Shoulder Stiffness after rotator cuff repair Cause Stiffness after Cuff Repair Very common!! Normally motion recovers with time Resolves within 6-12 months Vastamäki, et al, Scand J Surg, 2014 Quick recovery may lead to failure Slow recovery or stiffness more likely to heal! McNamara, Murrell, et al, JBJS Am, 2016 Stiffness after Cuff Repair Moderate & severe stiffness Relevant factors Preop stiffness Diabetes Worker s comp Surgery rarely required (less than 1%) Namdari & Green, JSES, 2010 Severe & Refractory Stiffness After rotator cuff repair Possible causes Poor surgery Poor postop management Arm position Pain control Prolonged postop pain!! Severe & Refractory Stiffness After rotator cuff repair Prolonged postop pain RI Capsular shrinkage SAB adhesion Global stiffness 4

Sliding) procedure Ando, Sugaya, et al, Arthroscopy, 2012 AS RATS Procedure Arthroscopic RATS!! 1. Remove scar tissue @ RI 2. Resume transverse sliding of the SSC 3.

5 Post-Surgical Stiff Shoulder Arthroscopic RATS!! After Instability repair Selective loss of side Homogeneous scar RI and anterior capsule Limits transverse motion of the SSC tendon AS RATS (Restoration of Anterior Transverse Sliding) procedure Ando, Sugaya, et al, Arthroscopy, 2012 AS RATS Procedure Arthroscopic RATS!! 1. Remove scar RI 2. Resume transverse sliding of the SSC 3. Release cranial portion of IGHL Ando, Sugaya, et al, Arthroscopy, 2012 Selective Loss of ER After instability repair Longer immobilization? Surgical procedure itself? Prolonged postoperative pain Scar & adhesion restricts transverse sliding of the SSC Ando, Sugaya, et al, Arthroscopy, 2012 Refractory Stiffness after RCR Global stiffness Almost pain free Poor rotator cuff function Physiotherapy Resume cuff function difficult FF can improve, but ER difficult 5

$Refractory Stiffness after RCR$ Poor rotator cuff function Surgery

6 Refractory Stiffness after RCR Global stiffness Almost pain free Poor rotator cuff function Surgery RATS & global release Postop physio! 6

Rehabilitation Following Rotator Cuff Repair: When Should We Start and What Should We Do? Martin J. Kelley, PT, DPT, OCS. Dangerous Territory 3/9/2018

Rehabilitation Following Rotator Cuff Repair: When Should We Start and What Should We Do? Martin J. Kelley, PT, DPT, OCS Dangerous Territory Rotator Cuff/capsuloligamentous Complex 1 The Rotator Cuff Tear